Provider Demographics
NPI:1487206421
Name:ROUSH, ANDREA RAE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:RAE
Last Name:ROUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1562
Mailing Address - Country:US
Mailing Address - Phone:740-441-1949
Mailing Address - Fax:740-446-5982
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:554-465-9378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025077363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner